Case presentation
An 85-year-old man with dysphagia was admitted to our hospital. Computed
tomography (CT) revealed prolapse of a massive hiatal hernia involving
the stomach (Fig.1a) and pancreatic body (Fig.1b). His CT findings also
showed an 8-mm enhanced solid component in the cyst, which was found in
the pancreas body (Fig.1c). We suspected that an intraductal papillary
mucinous neoplasm was the most likely diagnosis, and surgery was
indicated. We performed hiatal hernia repair, followed by laparoscopic
distal pancreatectomy. Ports were placed in the umbilical region,
bilateral hypochondria, and bilateral upper abdomen. A large hiatal
hernia was also observed. A large part of the stomach had prolapsed into
the mediastinum (Fig2a). The adhesion between the hernia sac and the
omentum was peeled off. The hernia orifice was sutured with a
non-absorbable thread while pulling the esophagogastric junction
(Fig2b). Fundoplication was performed from the front, and hiatal hernia
repair was completed. Distal pancreatomy was then performed using five
ports. The pancreas then returned to its normal position. Tunneling of
the pancreatic parenchyma was performed immediately above the portal
vein. The pancreatic parenchyma was dissected using a laparoscopic
linear stapler (Fig2c). Splenic arteries and veins were dissected. The
pancreatic tail and spleen were detached from the retroperitoneum, and
the specimen was removed. In this case, gastric stasis occurred but
improved conservatively. Esophageal reflux was not observed, and the
patient was transferred to another hospital on postoperative day 13.